Symptoms attributable to the gastroduodenal area are classified into five categories:
Must fulfill both:
1. One or more: bothersome postprandial fullness, early satiation, epigastric pain, epigastric burning
2. No evidence of structural/systemic/metabolic disease explaining symptoms
Required (≥2 days/week):
Associated features:
Required (≥1 day/week):
Provisional subcategories:
Must include ALL:
1. Bothersome nausea ≥2 days/week with or without ≥1 vomiting episode/week
2. Exclude: self-induced vomiting, eating disorders, regurgitation, rumination as cause
3. No evidence of structural/systematic/metabolic disease on routine investigations
4. Symptoms predominantly due to PDS → exclude diagnosis
5. Predominant nausea/persistent vomiting with delayed GE → prompt gastroparesis diagnosis
Must include ALL:
1. Stereotypical repetitive vomiting episodes regarding onset (acute) and duration (up to 10 days)
2. ≥3 discrete episodes in prior year, ≥2 episodes in past 6 months, occurring ≥1 week apart
3. Milder symptoms (nausea, isolated vomiting) can be present between cycles
Must include ALL:
1. Stereotypical episodic vomiting resembling CVS in onset, duration, frequency
2. Presentation after prolonged (≥1 year) and excessive (≥4 days/week and/or ≥15 doses/week) cannabis use
3. Relief of vomiting episodes by sustained (≥6 months or 3 typical emetic cycles) cessation of cannabis use
Triggers of flares:
Psychiatric comorbidity: 78% of adults with CVS screen positive for depression, 84% positive for anxiety
Differential diagnosis includes:
Diagnostic testing dictated by clinical presentation:
Four phases characterized:
1. Prodrome: nausea, abdominal pain, fatigue, weakness → initial presentation, can be stereotypical in timing
2. Emetic phase: 3–6 days, unrelenting vomiting >8 times/hour on average → within minutes to hours after prodrome
3. Recovery phase: up to 1 week → persistence of nausea, lightheadedness, meal intolerance in some patients
4. Interepisodic phase: weeks to months duration
Additional findings:
Diagnostic testing: performed only to exclude other causes of chronic nausea/vomiting → negligible yield
Four phases similar to CVS:
Compulsive bathing behaviors: 92% of patients report to reduce vomiting and pain during attacks
Factors associated with CHS diagnosis:
Diagnostic challenges: confirming symptom resolution after cannabis cessation → roadblock in many cases
Testing: rarely indicated in absence of complications (e.g., hemorrhage)
Abortive treatment: may not be feasible if prodrome is short; non-oral treatments most likely beneficial after emesis starts
Preventive treatment:
Abortive therapies:
Preventive therapy: CHS responds poorly to TCA
1. Supragastric belching strongly supported by observing frequent, repetitive belching
2. Supragastric belching can be interrupted by maneuvers or distraction
3. Excessive gastric belching: no defining clinical correlate
4. Intraluminal esophageal impedance measurement (with or without manometry): allows objective differentiation of supragastric vs gastric belches